EverythingHealth is designed to address the rapid changes in Science, Medicine, Health and Healing in the 21st Century. This site will sift through the vast amount of confusing data and simplify issues that are of interest to everyone interested in a healthy life and longevity. The writings on EverythingHealth are entirely my own views and opinions.

Thursday, October 30, 2008

Halloween has been celebrated since ancient times and the Druids, an ancient order of Celtic priests in Britain, believed that on the night before November 1 (Oct. 31), Samhain, the lord of the dead, called all the wicked spirits together. Since the Druids were afraid of these spirits, they chose that day to sacrifice, hoping they would be protected.

During the middle ages, the Roman Catholic Church decided to allow new converts to maintain some of their pagan (Druid) feasts. But now they were switched to "Christian" feasts so they would pray to and remember the deaths of saints. November 1 is"All Saints Day" and October 31 was supposed to be "All Hallowed Evening".

Modern Halloween and trick or treating comes from Ireland. Irish farmers went from house to house begging for food to be used at the village Halloween celebration. They promised good luck to those who gave them good food and a trick to those who refused.

For little goblins and witches in the United States, Halloween is a night to dress up and go trick or treating. Somehow it has turned into a candy nightmare for parents as the kids compete to see how much candy they can accumulate in one bag. 73% of Americans participate in Halloween and the average family spends $40.00 on costumes, candy and decorations. (It might be less this year with the scary economy!)

To keep kids from gorging on unhealthy, high fructose corn syrup candy, it takes a little planning.

Most guides say to give away unused candy. Remember, candy is junk food, so send it to the dump instead. Why poison someone else because you feel guilty throwing away candy. It's not actual food, so get it out of your mind that it is a food option. Of course candy is part of the fun of Halloween but once the night is over, most kids won't notice if the bag is gone. Let little Johnny pick out several of his favorites to be saved for the next week of school lunches and toss the rest.

Wednesday, October 29, 2008

There are at least 5 things wrong with this offering that I (and presumably many other doctors) received in my mail this week. Perhaps you can think of more:

#1. What is this thing? Balance is a big problem for seniors. A patient might think this is a high-tech, evidence based devise for diagnosis and treatment. Since the Medicare patient is far removed from paying the cost, it would be easy for a physician to do balance testing on all of his senior patients.

#3. "5 minute serial evaluations to assess treatment" means the doctor can churn and churn and bill Medicare $475-700 over and over as you retest the patient to see if your treatment (?) is working.

#4. "You can prevent falls in your patients if you know the problem". Through comprehensive physical exam, blood testing and evaluation, I diagnose balance problems all the time. They are multifactoral and very very hard to treat in elderly people. The VatENGplus doesn't add to the solution and may well divert money away from much needed primary care.

#5. This is another "technology" that is offered to doctors as a legitimate way to increase revenue because Medicare doesn't pay enough for thinking, diagnosing, evaluating and caring for patients without gimmicks.

Monday, October 27, 2008

The Happy Hospitalist wrote a blog that addresses many issues in health care. It answers why doctors are fleeing from primary care specialties into the procedure specialties (Derm, GI, Cardiology, Interventional Radiology, Urology, Anesthesiology, Surgery). It also gives a peak into the Byzantine coding requirements that are required of Physicians by Medicare and continued by every health insurer. It also explains how crazy and inequitable the reimbursement schemes are in Medicine and why we have runaway costs. Here is a sneak peak...but read his entire post.

"How does the AMA define a 99232?

Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient's hospital floor or unit.

25 minutes? Really. In my state a 99232 pays $6o. That works out to $144 an hour if in fact a 99232 really took 25 minutes. A colonoscopy without specimen collection (45378), pays about $180 if it's done at the hospital, $330, if it's done at the docs office. If you do a single biopsy (45380), it pays $220, if done at the hospital, $400 if it's done at the docs office. I'm pretty certain after several thousand of 'em, I could do at least two an hour, maybe three. This also explains why every colonoscopy has a random biopsy. You would be throwing away $80 an hour not to do it. You do the math. $144 an hour for cognitive care, or $800 an hour or more for screening colonoscopies at the office. "

Genetically modified tomatoes that are rich in purple antioxidants called anthocyanins cause cancer prone mice to live longer. Tests on mice that lacked the p53 gene, which helps protect against cancer, showed the mice that were fed the purple tomatoes lived 30% longer than those who ate only normal red tomatoes.

British researchers from the John Innes Centre, Norwich, England, published their results this week in Nature Biotechnology. They were investigating ways to increase the levels of antioxidants in common fruits and vegetables. Tomatoes naturally contain the beneficial antioxidant compounds, lycopene and flavonoids. By taking two genes from the snapdragon plant and turning them on in the tomato, they were able to create a genetically modified fruit that added the antioxidant, anthocyanin.

The researchers created the purple tomatoes by linking the two genes from the snapdragon flower with a regular tomato plant. The anthocyanins give the tomatoes a purple color. Although the results were preliminary, scientists are hopeful that the new purple tomatoes may help cancer patients in the future.

Anthocyanins offer protection against certain cancers, cardiovascular disease and age-related degenerative diseases. There is also evidence that anthocyanins have anti-inflammatory activity and hinder obesity and diabetes. Research has shown that natural dark purple pigments in fruits, vegetables and berries have beneficial health benefits. Other powerhouse fruits that contain anthocyanins are blackberries, blueberries, cranberries and currants.

This is more evidence that what you eat can have a profound impact on your health and longevity. Since most people do not eat the recommended five fruits and vegetables a day, it is exciting to see new techniques that may boost the benefits of the fruits we eat.

The research was funded by the EU and by JIC's core strategic grant from Biotechnology and Biological Sciences Research Council (BBSRC).

Sunday, October 26, 2008

Senator Obama wants to provide universal health care coverage to all Americans, but the physician shortage will stop it dead in it’s tracts. With less than 2% of medical students choosing primary care medicine as a specialty and the aging physician population that is ready to retire within the next five years, we have a crisis looming.

It is the primary care specialties who manage 80% of all health care needs of our population and who keep costs under control by knowing the patient and providing continuity and preventive care. As they retire or close their practices to new patients, there are no young physicians to take their place.

There is already a shortage of primary care physicians and physicians in some basic specialties like general surgery, neurology and rheumatology. Even large metropolitan areas are lacking in gerontologists, general internists and family physicians. Rural communities face challenges for primary care and specialty care.

Young physicians in training are turned off by the enormous unsatisfying paperwork and difficult practice environment of primary care. Our reimbursement system has disadvantaged these physicians for years and they are at the bottom end of the income scale, despite the fact that they are the basis for a healthy population. Primary care doctors spend more time talking with patients and managing health care without expensive procedures and tests. The reimbursement for these cognitive services are not keeping up with the costs of running a practice and young doctors are walking away from this type of practice in favor of better lifestyles and more pay.

Even in medical strongholds like Boston, Mass., where there are several academic teaching hospitals and wonderful medical care, there is such a shortage of primary care physicians that doctors and nurses can’t find a doctor to care for their own family. Finding a good primary care physician requires “knowing someone” who can open the door for you to be seen as a patient.

The proposal to provide insurance for the 45 million Americans who are presently uninsured will fall flat unless we address this critical issue of primary care and who is going to take care of people. Having insurance is not the same as having access to care.

Episodic, expensive, high-tech, specialty services have created a monetary health crisis that looms larger than the banking meltdown. It is time we look at the primary care crisis and begin finding solutions that will allow health care reform to succeed. Without considering the primary care piece, it is doomed to failure.

Thursday, October 23, 2008

The J Natl Cancer Inst. has published reassuring findings from a case control study. Women with BRCA1 mutations have a lifetime risk for breast cancer of 60-80%. Many of these women undergo prophylactic oophorectomy (removal of the ovaries) before menopause as a way to lower their risk. This surgery can cause severe, sometimes disabling symptoms of menopause and really affect a woman's quality of life. Because of the concerns about breast cancer, these women are afraid to use hormone replacement to relieve symptoms.

This study, supported by the N.I.H., looked at 472 women and matched them with controls. They found that there was no evidence of higher breast cancer with hormone therapy use in BRCA1 mutation carriers and it even provided a surprising suggestion that hormones could be protective. This important study allows us to reassure women with BRCA1 mutations that use of menopausal hormones are OK to relieve severe symptoms of menopause.

The answer to the image from yesterday and another image above is#5- psoriasis.

Psoriasis is a common condition and affects the skin with patches of raised red patches with silvery scales. In the United States, about 7 million people have psoriasis. As you can see, it can also affect the fingernails and toenails. In people with skin psoriasis, 10-55% have psoriatic nail disease and 10-20% also have psoriatic arthritis. Of people with psoriatric arthritis, 50-85% have affected nails.

Just out from the British Medical Journal; Eating until you feel full and eating fast are associated with being overweight.

Obesity has become a worldwide problem in developed countries and the highest selling books are cookbooks and diet books. Obesity is an important risk factor for cancer, cardiovascular diseases and diabetes. This study gives us more evidence on how we can help people with weight control.

The researchers studied 4140 Japanese adults and measured their body mass index. They used a validated survey to assess speed of eating (very slow, slow, medium, fast, very fast) and they also asked about eating until full.

They found that for both sexes, those that reported eating until full and eating quickly had the highest age adjusted values for weight, body mass index and total energy intake. They further adjusted for total fibre intake, alcohol, smoking and physical activity and still found that eating quickly made you fatter. For patients who both ate quickly and ate until full there was a "supra-additive" effect on being overweight.

With all of the diets around and advice given to help people lose weight, just having them chew their food more slowly would help. Remember what grandma used to say "Quit gobbling your food. Sit there and chew". She was right. Grandma also said " Stop gorging. You're not a pig" Well, right again.

Grandma's wisdom and the British Medical Journal have the last word: Portion size and small plates are known to be effective weight controls.

Saturday, October 18, 2008

There is trouble in paradise. The big Island, Hawaii, is experiencing a massive doctor shortage and there is no relief in sight. Here are some facts that might be as surprising to you as they were to me.

There are 140,000 residents on Hawaii, the biggest of all the Hawaiian islands at over 4,000 square miles. There are three hospitals on Hawaii, 2 are state hospitals and one is private and they are all financially desperate.

For the 140,000 residents and thousands more tourists who visit, there is only one orthopedic surgeon who operates. Two ortho docs left this year because they just couldn't make it financially. There are no neurosurgeons and only two OB/GYN doctors after three retired this year.

There is one health insurance carrier who enjoys a monopoly (Blue Cross Blue Shield-HMSA) and, according the the physicians I spoke with, they have terrible reimbursement rates that make it impossible for physicians to practice here. Couple that with the " lower than cost" rates paid by Medicare and you have a system that just doesn't work

Hawaii had enacted "universal coverage" for children through HMSA and that program was cancelled after just 11 months and coverage for 2000 kids. Budget shortfalls caused the program to be abandoned.

The final nail in the coffin for doctors in Hawaii is the high cost of malpractice insurance. That one orthopedic surgeon on the Big Island pays at least $47,000 a year. Tort reform and caps on pain and suffering payments would go a long way toward stabilizing the physician workforce and allowing more doctors to practice in paradise.

There is one take home message here. Who we elect has a critical impact on our health care. Health care policy is the most important aspect of the health of a population. No doctors means no care. It doesn't matter if you have insurance if there is no one to take care of you.

Friday, October 17, 2008

I am currently out of town for a medical meeting and although I have been gone less than 24 hours I have received 7 phone calls or emails from patients and my office about pharmacy medication renewals. It is only 10:00 AM back home so that number will increase as the day goes on. If you query any primary care doctor, you will find that 9/10 will report pharmacy and drug renewals are one of the most annoying and time wasting hassles they have. (not a scientific study but if you doctors out there disagree, just tell me).

We deal with many different pharmacies, mail order drug companies and pharmacy benefit companies, each with their own rules, regulations, protocols and coverage. Patients have no idea what goes into getting them one simple medication. Here are just a few of the idiosyncrasies:

Controlled drugs (even common pain meds) and any drug for Medicaid patients needs to be written on a special tamper proof pad. They cannot be faxed or phoned in. They need to have the patient's address (making it impossible for an on-call doctor to help).

Pharmacies tell patients the drug has not been renewed when it has, prompting multiple phone calls back and forth and lots of finger pointing.

When I write for 12 renewals so I won't get a phone call each month, or the patient won't be hassled each month...the pharmacy ignores it and calls anyway.

If a patient needs more medication because they are going on vacation, the pharmacy will not allow more than one month..creating phone calls and angst.

Mail order pharmacies substitute different (cheaper for them) medications and patients are confused and call me.

Patients run out of medication or don't take their medicine on a trip and call frantic for the renewal "right now". Each of these calls requires the chart to be pulled and the doctor to get involved "right now".

I can't even begin to describe Medicare Part D.

This is the most inefficient and ridiculous way to practice medicine, provide good service to patients and insure everyone gets the right care and the right time.

Having electronic prescriptions will help but even that only works for the pharmacies that are hooked in on-line and it doesn't solve the mail order problems or the controlled substance problems.

Tuesday, October 14, 2008

This photo shows the earlobe of a 21 year old woman who presented to a clinic with a growing hard red nodule that was located where she had her ear pierced 5 years ago. She removed the earring after a few years because it never healed and was always inflamed.

A biopsy was done of the nodule and pathology showed a skin reaction with epithelioid histiocytes surrounded by a dense infiltrate of lymphocytes.

Allergic patch testing was done and it showed a positive reaction to nickel and a strong reaction to palladium. The skin reaction to palladium (done on her back) persisted for months and was not relieved with strong corticosteroid cream.

The reaction on her skin finally disappeared after injecting it with corticosteroids. The ear lesion required surgical excision.

Allergies to metals are common and any piercing that does not heal may be an allergic reaction to one of the metals or alloys used in the metal. Similar cases have occurred with nickel, gold and platinum from ear piercings.

Sunday, October 12, 2008

On Tuesday, October 7, Lisa Marie Presley gave birth to twin girls. The only child of music icon, Elvis Presley, has two teenage children from another marriage and these are her first babies with music producer husband, Michael Lockwood.

The girls were born to the 40-year-old mother by Caesarian section and weighed 5 lbs, 15 oz. and 5 lbs. 2 ozs and are reportedly doing very well. Twins run in the Presley family. Elvis was a twin and her mother, Priscilla Presley, has younger brothers who are twins.

Lisa Presley’s daughters are fraternal or dizygotic twins. That means they are non identical and are from two ova (eggs) fertilized by two separate sperm at the same time. The mother must release two eggs for a possibility of fraternal twins. They implant in the uterus separately and grow like siblings together. Dizygotic twins occur more commonly in mothers over the age of 35 and with the advent of fertility treatments the rate has exploded. Fertility treatments stimulate the uterus to produce many more eggs through each cycle. Triplet births have also increased due to fertility treatments.

Monozygotic twins, also known as identical twins, occur when a single egg is fertilized and then divides into two separate embryos. Depending upon when the split occurs, each embryo will either share a placenta or develop their own within the womb. These twins are nearly identical and are always the same sex. The likelihood of a single fertilization resulting in a monozygotic twin is an uncommon and random event and is not a hereditary trait.

Saturday, October 11, 2008

Get smart this weekend. National Public Radio has a long-running radio show called "This American Life" that is entertaining, thought provoking and just plain excellent. I downoad it automatically from I-Tunes and listen when I am driving in my car. Last weeks show was about the financial meltdown and the bailout and it is one of the best explanations of the entire mess and how it occurred. Listen and learn.

Thursday, October 9, 2008

One of the most brilliant and provocative writers of our time is Nicholas D. Kristof, who has made it his life's work to expose the horrors against women in third world countries around the world.In his Op-Ed, "Can This Be Pro-Life" he shines a spotlight on the Republican Right (which includes President Bush, Senator McCain, Governor Palin and their supporters) and how pro-life policies have a devastating effect on women around the world.

The opposition to condoms and birth control have had a terrible effect on women in Africa and Asia as they contract AIDS and fall further into poverty with unwanted pregnancies. Since 2002, President Bush - backed by Senator McCain- has stopped funding the UN Population Fund which works in 140 developing countries and has international support.

Now, the U.S. Agency for International Development has ordered six African countries to ensure that no U.S. financed condoms, birth control pills, IUDs or other contraceptives are furnished to a British Based aide group that operates clinics in poor countries. These clinics are often the only health care provided in rural areas where women walk for miles to receive care. The result will be at least 157,000 additional unwanted pregnancies per year, leading to 62,000 additional abortions and 660 women dying in childbirth.

These "pro-life" policies have dire effects on women and in countries where childbirth is the most common cause of death in young women, "pro-life" translates into "pro-death".

Tuesday, October 7, 2008

New guidelines from the Department of Health and Human Services recommend adults exercise a minimum of 2 1/2 hours a week for optimal health. That's right, two and a half hours a week. Raking leaves, walking around the block or doing resistance bands seem to count.

Now I do understand that half of all adults are really sluggish and don't get this much exercise. I also understand that getting people to move "a little" is better than nothing at all. But considering all previous studies have shown that for optimal health, an hour a day of aerobic exercise is needed, this seems a little "dummied down". We are in the midst of an obesity epidemic and diabetes crisis and raking leaves is not going to shift the pendulum to the healthy side.

Somehow these new recommendations fit with everything that we are hearing from our government now. Mediocrity is where we are headed. There are no stretch goals being presented. No need to develop new forms of energy ("drill, baby, drill"). No need to pull together as a nation to stop the genocide in Darfur or step up to the plate as a world leader. It's enough keep the economy going by spending money and that tax stimulus refund really helped, didn't it?

I will embrace the leader who asks me to set my vision high and strive for the best. In health, especially, I want the HHS to give me real science on what works and what doesn't. I don't want to just be pandered to; I want optimal health.

The cause of crib death, or sudden infant death syndrome (SIDS) has been a mystery for years. New findings published in The Archives of Pediatrics and Adolescent Medicine show that placing a fan in the baby’s room can decrease crib death by 72%

Pediatricians have recommended placing babies on their backs instead of their stomachs to sleep and this has lowered the number of SIDS deaths by more than half. Despite this, SIDS continues to be the leading cause of death in babies under the age of one.

The latest research was conducted with an NIH grant by Kaiser Permanente Northern California and included 497 infants. The researchers interviewed mothers of 185 infants who died from SIDS and compared them with 312 infants of similar race and age. They found that the simple use of a fan, in conjunction with having the babies sleep on their backs, avoid soft bedding, not share a bed with other children and use a pacifier, dropped the risk by 72%.

This study did not answer the question of why the fan is effective. Perhaps the circulation of air by the fan moves exhaled carbon dioxide away from the baby’s face. There have been some accounts of SIDS babies having brain abnormalities that prevent them from gasping and awakening when they do not get enough oxygen. SIDS deaths are most likely to occur when babies are between the ages of two months and four months, and deaths peak in the winter months. Some theories of "why" include the fact that rooms are more stuffy, there is less ventilation and more covers are used. Sleeping in a room with an open window was also found to lower risk, although the association was not significant.

Other recommendations to keep babies safe come from the American Academy of Pediatrics and they include:

• Not sharing the bed when parents are sleeping• Infants should be put to sleep on a firm mattress and soft objects, stuffed toys, pillows and quilts should be removed from the bed.• Avoid overheating and the room they sleep in should not be too hot.• Mothers should not smoke and babies should not be exposed to second hand smoke. Smoking during pregnancy is one of the strongest risk factors for SIDS

Sunday, October 5, 2008

Researchers at Yale University have rated the top 100 foods based on nutrients, vitamins, sugar and salt as well as impact on blood pressure and other health concerns. The quality index scores of the healthiest foods to eat will soon be posted in major grocery stores to help consumers make choices. Shopping by the numbers may help us all on the confusing trips to the grocery stores with over 45,000 products to chose from. Here are the top choices and it is no surprise they are all natural.The top four got ratings of 100:

BroccoliBlueberriesOrangeGreen Beans

These were closely followed by:Pineapple,RadishSummer SquashAppleGreen Cabbage and TomatoeNonfat milk

Other foods that had ratings in the top 50 were sometimes a surprise:Raw AlmondsBrown RiceSnapperCanned Tuna in oil, drained

Unbuttered, unsalted popcorn came in at #69Pasta was #50 and ranked above prunes and vanilla yogurt

Heading up the bottom of the healthy (bottom=unhealthy) food list were:

Saturday, October 4, 2008

Do you want to write a book? Drink less coffee? Clean that garage? Loose weight? The world is paved with good intentions, right? Well, I found a new website that I want to share because I think it is really cool. It is called Stickk.com.

This site helps you stick to goals by having you make commitment contracts and engage your friends and lovers to keep you on track. Dean Karlan, economics professor at Yale and co-founder of Stickk says the commitment contract concept is based on two well known principals of behavioral economics: 1.People don't always do what they claim they want to do, and 2.Incentives get people to do things.

At Stickk you make your commitment, invite your friends to be your coach and referee and then you put money up as an incentive. If you succeed your money is returned to you. If you fail to live up to your commitment (you define it), your money goes to a charity of your choice or, even more motivating...an anti-charity.

Are you a staunch pro-life person? I bet you'd hate to see your money go to pro-choice organization NARAL. Do you think marriage between a man and woman is sacred? Your anti-charity would be Freedom to Marry.

Or you can do like I did and choose The George W. Bush Presidential Library to receive your donation if you don't meet your commitment.

According to Jordan Goldberg, the CEO, "78% of the users who designate a referee and have money on the line are successful."

My coaches are keeping me on track and encouraging me to meet my goal and I sure don't want that presidential library to get my hard earned money!

Friday, October 3, 2008

The anticipated VP debate has ended and both candidates held their own, but there was barely a mention of one of the most pressing issues in the United States…health care. Health care inequities and the rising costs have been a concern of Americans for a long time. I know the Wall Street meltdown has eclipsed most everything but I once you describe the “orgy of Wall Street and the greed of big business” for the 10th time, it’s time to move on and talk about your policies for change.

Palin touched on the subject by mentioning the $5,000 tax credit McCain would give for people to buy their own insurance. Biden countered with a long winded (but accurate) explanation of how $5000 wouldn’t really be enough to cover a policy that now costs $12,000 and is currently subsidized with tax breaks to employers.

That was it…end of discussion. What wasn’t said is that McCain’s health proposal would eliminate the tax benefits employers now get so more people would be dropped from work based health care. It would be every man for himself on the open market trying to qualify for insurance, figure out what is covered and purchase policies on their own (with $5,000 credit).

For anyone who has dealt with their insurer and tried to find out what is covered, what their share of charges would be, how to get their doctors paid, how to battle denial of care when they are sick, the McCain plan puts more control (and money) into the hands of insurers. There are no provisions for universal coverage. There are no prohibitions on insurers refusing to cover sick people.

Here’s how it works now in the free marketplace. If you try to buy insurance yourself you must disclose all health risks as well as prior treatments. All past medical records are reviewed by underwriting. I’ve had patients refused coverage for pink eye, prior abnormal (but benign) pap tests, sinusitis, depression, anxiety, abnormal (but benign) mammograms, urinary tract infections, and hair loss. If you have had cancer, diabetes, hypertension etc etc etc you will pay enormous rates or be refused outright. This is called “good business underwriting” and for companies whose goal is to produce profits for shareholders this is the way it should be done.

Is this what we want for our U.S. health care policy?

I will be watching the next debate and I would like to see health care covered in detail, just like they talk on and on about drilling for oil. Everyone knows that is not a solution for our energy policy but that doesn’t stop the discussion. Lets bring health care back into the dialog.

Thursday, October 2, 2008

This post from fellow blogger, Buckeye Surgeon, really makes you think twice about blogging. Most medical bloggers are anonymous but I write Everythinghealth with my real name. It keeps me from ranting and raving and makes me more careful about what I write. But reading about this stalker who didn't like what Dr. Parks of Ohio wrote, is a bit chilling. Crazy world!

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About Me

I am an Internal Medicine physician who has practiced for over 35 years in Northern California. I was previously the President of the SF Medical Society and Chief of Staff at a large academic medical center. I am most recently the Chief Executive Officer for a large Physician and health care provider group in Northern
California. My practice is smaller now
but caring for patients is still the most important part of my work. I love taking care of patients one:one as well as influencing health care at a larger level.
The information on this site is not designed to replace a physician's advice.
This site is self funded. Advertisers are welcome but will be clearly identified.